British IournalofUroZogy (1995). 76, Suppl. 2, 55-57

Ethical issues in healthcare prioritization: a political viewpoint LORI) McCOLL OF DUNHILL Gug's Hospital, London, UK

Healthcare prioritization

In the politically charged healthcare climate, it is difficult to imagine how a reasoned and well-constructed debate regarding the ethics of healthcare prioritization will ever take place. As the dust settles on some of the recent reforms, it appears that there is a growing acceptance of the need for the reforms. With 90% of health and community healthcare provided by trusts and over 1200 general practitioner (GP) fundholding practices, the reforms have taken root. In the midst of the accusations of underfunding, over El00 million per day continues to be spent on the health service, the number of patients treated has increased, and waiting times and the num- bers waiting for treatment have been reduced radically.

Surprisingly, the main obstacle to these changes was not the Labour Party, which has now adopted some of these policies, but sections of the media who were less concerned with the complex problems of running a health service for the benefit of all, than about creating sensational headlines that would sell front pages. Since the reforms began, the media has made the service a political football, which it has kicked whenever it suits, regardless of the chaos that it brings to those working in the service and the fear to all who rely on its excellence. Furthermore, some journalists have ignored evidence from the public which has been contrary to their own case. A survey in 1993 by the Citizens' Charter Unit [l] stated that 67% of users of hospital services and 88% of users of GP services, thought that care in hospitals had improved or remained constant in the previous year.

As progress is made regarding the ethics of healthcare prioritization, media activity will be the hardest obstacle to overcome in the pursuit of a reasoned and well- informed debate. Recently, a young girl suffering from leukaemia was thought by her clinicians to have very poor prospects of recovery, and this was confirmed by second and third opinions at other specialist hospitals. The decision not to proceed to repeated radical treatment was made purely on clinical and humanitarian grounds and had nothing to do with resources. The media pretended to be outraged and blamed underfunding and savage cuts for this, and a benefactor came forward for the young girl to be treated privately. What was a

complex decision regarding prioritization became a media sensation story. It is significant that the reaction of the media is the first problem when seeking to introduce a sensible debate on healthcare prioritization.

A second point that needs to be stated regarding the prioritization of resources is that the dilemma is not new and is not the result of government reforms. The issue has been around since the beginning of healthcare itself, but it is now more visible and openly debated. What in the past was discussed and debated privately amongst doctors is now debated in public and with healthcare managers. This is to be welcomed. Furthermore, the technological revolution in healthcare has made the issue a more pronounced and difficult subject. As people's expectations rise, and the costs of equipment rise simi- larly, then difficult decisions have to be taken regarding appropriate spending.

Ethicists will argue over the individual cases: however. a decision of this nature needs to be made by balancing the rights of the individual with the needs of the popu- lation at large. The two appear to be in conflict and if a considerable sum of money is spent on a single patient, either through the provision of treatment or drugs, then there will be less for the needs of the wider community. The autonomy of the patient is in conflict with the widely accepted philosophy of utilitarianism, which seeks to provide the greatest happiness to the greatest number of people. In cases like this, prioritization is not only a matter of money but of manpower, skills and facilities.

Finding a way through the ethical dilemma is difficult and in the past mistakes have been made. Prioritization has failed for a combination of factors, many of which originate with the mistakes of politicians as well as the medical profession. There has been a genuine but mis- placed enthusiasm by some clinicians to promote their own techniques and operations that might not necessar- ily be the best way to spend resources. Thousands of operations were undertaken to remove tonsils and aden- oids, which at the time was considered to be the best way to proceed: however, with the benefit of hindsight, we know that many of these operations were unnecessary.

Other mistakes have been made through inappropriate developments. The medical profession has enjoyed its share of empire builders who have wanted to increase

0 1995 British Journal of Urology 5 5

56 PROFESSOR THE LORD McCOLL

the size of their own departments for a variety of reasons, both good and bad. Again with the benefit of hindsight, some of the developments have been of questionable significance and the resources could have been used in other ways.

A further influence on prioritization debates has been the members of the profession who are regularly heard on television, stating that their patients on waiting lists are dying through lack of resources. Using their belief that ‘he who shouts the loudest gets the most’, they have regularly sought to attract substantial resources to their own work. Recent attempts to reform the provision of healthcare in London have met with significant num- bers of individuals taking this approach. Despite 20 reports over many years having called for reforms in the structure of London healthcare, effective prioritization has in the past proved almost impossible in such a climate.

Learning from these past mistakes, there is a growing desire in the health service to spend the €40 billion annual budget as effectively and as fairly as possible. To reach this goal, there needs to be some common ground on the purpose of healthcare. For some, and this seems to be the most sensible viewpoint, healthcare is a means to an end, namely a better existence and a more fulfilling quality of life. This means that the resources will follow the need, the main goal of the current reforms. For others, healthcare has become an end in itself, with resources wasted and the needs of the patients largely ignored.

An understanding of the purpose of healthcare is critical when making an ethically correct decision regarding prioritization. If healthcare is a means to an end then a decision can be made effectively regarding appropriate and inappropriate treatment and what is in the best interest of the patient. The question of resources is secondary to such a decision. However, if healthcare is an end in itself, then every issue, from patient care to the development of new facilities, will be a resource-led issue. So for some, hospitals must survive because they are institutions that serve the community, regardless of the fact that the community may have little need of the services provided, and such services could be provided from within the community more effectively than from the institution.

Finding common ground on the purpose of healthcare and the system we wish to develop is critical to the issue of health prioritization. A further important factor in making a just and fair allocation of resources is the provision of accurate and reliable information about outcome. This may be a difficult task, but as plans are laid for the future they can only be effective if they are based on sound clinical audit. The Royal Colleges have led the way in promoting audit, and for too long the

health service has avoided such analysis, perhaps because at times it is difficult to assess success. However. it is encouraging that the Department of Health has established a Clinical Outcomes Group. chaired jointly by the Chief Medical Officer and the Chief Nursing Officer. to find further ways of providing effective outcome information.

While the above committee is an effective group for examining outcome information, there may be a need for further consideration of the establishment of a national ethics committee. As recent cases have shown, the debate over resources and prioritization will intensify as decisions regarding the provision of treatment in a technological age are becoming increasingly more com- plex. Technology, the issue of resources and the need to define good medical practice, were brought sharply into focus by the case of Anthony Bland, the young boy tragically injured in the football disaster at Hillsborough and subsequently surviving in a persistent vegetative state (PVS). It was left to the courts to decide whether or not the doctors should persist with the provision of nutrition and hydration. Despite the denial of the Airedale Hospital NHS Trust, and the patient’s doctor Jim Howe, that resources had anything to do with the case, there was much discussion in the press regarding the allocation of resources to those in PVS.

Having been a member of the House of Lords’ Select Committee on Medical Ethics, which considered some of‘ these issues, I am increasingly aware of the need for a National Ethics Committee, which would advise the Secretary of State for Health on these matters. The committee, which might consist of a mixture of healthcare professionals, lawyers, ethicists, churchmen and lay people would assist in providing the highest quality guidance to the Family Division of the High Court, as it seeks to grapple with some of the more complex matters in the high-profile cases that often involve an element of resources prioritization.

There are other factors that can have a significant impact on the issue of resource prioritization, which have little to do with the €40 billion budget which the Treasury allots to the Department of Health. There is much talk about the right to health, but that right could be far more achievable if more people exercised a responsibility for their own health. Despite the provision of an adequate health service, many people fail to recognize the need for personal responsibility in healthcare. There is great comfort in having a free health service at the point of demand, which will pick up the bill if we need it. Some illness cannot be avoided: however, even with the greatest killers, cancer and heart disease, there is much that individuals can do to avoid the risk. Although there are differences of opinion on the recipe for good health, there is agreement that an

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individual should refrain from smoking, that alcohol should be limited and that body weight should be kept within the normal range by having a low-fat, high- roughage diet. Furthermore, personal dental care, an adequate intake of fluoride in drinking water, tablets or toothpaste will substantially decrease caries and dental expenses.

The Government’s Health of the Nation Paper [ 2 ] , launched in 1992, was widely commended as an excel- lent strategy document in defining objectives and provid- ing the means to achieve them. The World Health Organization (WHO) described it as a model for other countries to follow and even articles in the British Medical JournaI [3] and the Nursing Times [4] welcomed it as the start to the ‘real business of the National Health Service (NHS)’. Since its launch, statistical data reveal that there has been a number of successes. The Secretary of State for Health stated in November 1993 ‘a good foundation has been laid in the war against avoidable illness.’

The media have been helpful in embracing this mess- age, surprisingly through some of the soap operas. Producers of The Archers decided to devote one episode to the importance of a high roughage diet. The message was blended cleverly into the programme, which was therefore acceptable to listeners, whereas a straight- forward propaganda programme telling us what to do would have been ignored. Fifteen years ago the media embraced the message behind the green movement, and it has permanently influenced our lives. There is a need for a similar revolution in thinking with regards to our own health.

A final pointer regarding prioritization concerns the advance of technology. While the cost of the technologi- cal revolution in healthcare has often led to problems of prioritization, it has also brought with it significant savings. From antibiotics to chemotherapy, advances

have saved funds and enabled resources to be spent in other areas. A recent success has been the Government’s immunization programme for measles, which saved healthcare managers significant parts of their budgets. Through a Department of Health incentive scheme, doctors were encouraged with particular regard to child vaccinations. When an emergency situation arose at the end of 1994, a measles epidemic was prevented. The great effort of the vaccinators resulted in only six cases of measles being reported.

Making decisions regarding the prioritization of healthcare resources is not easy. Obviously, each case will need to be considered on its merits. The resources available will never be sufficient to meet the demand, and increasingly so as we embrace the expected demo- graphic changes of the next century. The fundamental issue is not the amount of money available or even the way it is managed, rather whether a constructive debate can be held which avoids the health of the nation becoming easy prey for media and political pundits alike.

References 1 The Citizen’s Charter Customers’ Survey. London, HMSO.

2 The Health of the Nation: A Strategy for Hcalth in England.

3 Gabbay J. The Health of the Nation. Br Med J 1992:

4 Clay T. The Clay Column. Nursing Standard 1992: 6(51):

1994, p. 1.

London: HMSO, 1992.

305: 129-30

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Author Professor the Lord McColl, MS, FRCS, FACS. Department of

Surgery, Guy’s Hospital, London SE1 9RT. UK.

British Journal of Urology (1995), 76, Suppl. 2 , 55-57